343 posters, 5 videos, 2 audios, 18 topics, 33 sessions, 263 authors, 202 institutions

24th Annual Pain Medicine Meeting 2025

November 13-15, 2025| JW Marriott Austin, Austin, Texas

2229101

Suspected Visceral Herpes Zoster Presenting as Flank Pain in a Patient with Renal Cell Carcinoma

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Poster Presenter

Bhavana Nangunuri

Authors

Bhavana Nangunuri

Affiliations

Schwab Rehabilitaion

Part of Topic

Medically Challenging Cases - Late Breaking

Suspected Visceral Herpes Zoster Presenting as Flank Pain in a Patient with Renal Cell Carcinoma

Bhavana Nangunuri1, MD; Sarah Libinfraid1, MD; Sabrina Foster, MS; Baljinder Bathla1, MD

1Schwab Rehabilitation Hospital

Introduction:

Herpes zoster (shingles) arises from reactivationof latent varicella zoster virus within the dorsalroot or cranial nerve ganglia
Classical presentation: unilateral, dermatomalpain and vesicular rash, often preceded by apainful prodrome
Visceral zoster: 5-10% of cases, usually inimmunocompromised patients, with theabdomen being involved in about 10% of cases
Presentations without rash or precedingcutaneous eruption complicate timelyrecognition and appropriate management

Objectives:

Highlight an unusual herpes zoster presentation
Demonstrate the difficulty in diagnosis of visceralshingles
Discuss treatments to reduce pain in visceralherpes zoster

Case report:

A 66-year-old male presented with acute right-sided flank pain in a dermatomal distributioncorresponding to the T11-T12 region
Workup: negative urinalysis; MRI of the lumbar spine demonstrated multilevel spondylosis with discbulges at L3–L4, L4–L5, and L5–S1 and a mass arising from the lower pole of the right kidney; CTabdomen with mass concerning for renal cell carcinoma but nephrology consult and second opinion reported mass was unlikely source of acute flank pain
The right flank pain was refractory to numerous conservative interventions (acupuncture, lumbar triggerpoint injections, interlaminar epidural steroid injection)

Figure 1: The area of the patient'spain is highlighted, with dermatomeT11 in yellow and T12 in red

Image A and B: These imagesdemonstrate the cutaneousinvolvement, with a vesicular rash inthe trigeminal V1 distribution. Theoriginal image was cropped toprotect the patient's identity. Patientconsent was obtained with specificapproval to use these images.

Results:

Substantial improvement (80% reduction) in right flank pain with right T11-T12 intercostal nerve block
2 weeks later, a painful vesicular rash in the trigeminal distribution followed by persistent facial paindeveloped
He was diagnosed with postherpetic trigeminal neuralgia for which he was treated with antiviral therapyand prednisone, resulting in 90% improvement

Discussion:

Visceral herpes zoster in immunocompromisedpatients can present with diagnostic challenges
Pain may occur independent of cutaneousinvolvement, mimicking musculoskeletal ormalignant etiologies
In this case, the onset of severe flank pain beforethe facial cutaneous involvement complicatedthe diagnosis
Maintaining suspicion for atypical zoster isessential, as timely antiviral therapy andtargeted nerve blocks can improve outcomes,reduce morbidity, and prevent unnecessaryinterventions

References:

Saguil A, Kane S, Mercado M, Lauters R. Herpes Zoster and Postherpetic Neuralgia:Prevention and Management. Am Fam Physician. 2017;96(10):656-663.

Whitley RJ. A 70-Year-Old Woman With Shingles: Review of Herpes Zoster. JAMA.2009;302(1):73–80. doi:10.1001/jama.2009.822

Benbernou A, Drolet M, Levin MJ, et al. Association between prodromal pain and theseverity of acute herpes zoster and utilization of health care resources. Eur J Pain.2011;15(10):1100-1106. doi:10.1016/j.ejpain.2011.04.014

Timotijevic A, Kodela P, Glušac V, Bokonjic S, Joksimovic B, Vera Gomez J, Ladin D, Dumic I.Disseminated Varicella-Zoster Virus Infection with Internal Organ Involvement: A ScopingReview of 156 Cases. Viruses. 2025; 17(8):1135. https://doi.org/10.3390/v17081135

Spernovasilis N, Raissaki M, Papakitsou I, et al. Visceral Varicella-Zoster Virus InfectionPresenting with Severe Abdominal Pain without a Rash in a Patient with Psoriatic ArthritisTreated with Infliximab Biosimilar and Steroids: A Case Report. Mediterr J Rheumatol.2021;32(3):280-284. Published 2021 Jun 25. doi:10.31138/mjr.32.3.280

Acknowlegements:

We would like to thank our patient for their trust andcontribution to this case report. Special thanks to Dr.Baljinder Bathla for his guidance and supportthroughout this project. We are also grateful toSchwab Rehabilitation for their continual support.